This is a descriptive study on the clinical features of COVID-19 patients in Third Affiliated Hospital of Sun Yat-sen University located in Guangzhou city. Nine (60%) patients were of severe type, and one of them needed treatment in ICU and still hospitalized in ICU for more than 70 days (from January 22nd, 2020). This reminds us not to underestimate the severity of COVID-19. Early recognition and judgement to severe type of COVID-19 patients are urgent and important in clinical practice, in order to make proper treatment and reduce death rate.
Our study showed retirement, Hubei residents and faster respiratory rate were more frequent in severe type patients. It is consistent with the results from Huang’s study , which compared COVID-19 patients with ICU care and no ICU care. Other data, including age, sex, smoking history, comorbidity, symptoms and signs, were similar. Although age was of no statistical differences between the two types, the elderly was thought to be related to retirement, comorbidity and progression to severe type in clinical practice. Hubei residents seemed to be “first generation”  or the next generation, infected with SARS-CoV-2 of relative strong virulence, making infection much more severe than patients from other cities. The common symptoms in COVID-19 patients includes fever, fatigue, myalgia, sore throat, cough, sputum production, dyspnea. These symptoms were also reported by other studies [12, 17]. Close attention should be paid to symptom diarrhea, which may be evidence for digestive system impairment. SARS-CoV-2 RNA could be detected in blood and anal swab specimens , that the virus invades circulatory and digestive systems. ACE2 was reported as a receptor for coronavirus replication , as it was highly expressed in lung and intestine tissues. Whether SARS-CoV-2 could invade urinary system is still unknown, as urinary irritation symptoms and signs were absent in our study. More studies are needed.
In terms of baseline laboratory tests, higher blood level of lactate dehydrogenase and lower Oxygenation Index were demonstrated in severe type patients. Lactate dehydrogenase is one of the important enzymes for anaerobic glycolysis and gluconeogenesis. Its elevation prompts liver, lung, heart and kidney diseases. Oxygenation Index, an item of blood gas analysis, reflects oxygenation capability of tissue and organ. Respiratory dysfunction is indicated if the Oxygenation Index is less than 300 mm Hg. Other biochemical parameters for inflammation, liver function, coagulation function, cardiac function, renal function and pulmonary function were similar in two groups. Interestingly, lymphopenia is seen in both groups without statistical difference, as it could be used as a reference index in the diagnosis of COVID-19. Dynamic observation of lymphocyte count may be used as a reference index in degree of severity.
Initial chest CT images in our study demonstrated that ground-glass opacities without consolidation were found in all patients without specificity. Bilateral involvement was found in 12 (80%) patients and multi-lobes involvement was found in 13 (86.7%) patients. Similar findings were reported [13, 14]. It was difficult to distinguish COVID-19 from other pneumonia in early stage by initial chest CT images. As there were no statistical differences between mild and severe type patients in initial chest CT findings in our study, it also seemed to be difficult to distinguish the two types from each other by initial chest CT images. However, subsequent consecutive chest CT examinations are necessary to assure the change of pneumonia and make proper treatment.
COVID-19 lacks of confirmed effective antiviral treatment. All the experience is from treatment for SARS-CoV and MERS-CoV infection. Combination of lopinavir and ritonavir was clinical beneficial among SARS-CoV patients . A placebo-controlled trial of interferon beta-1b, lopinavir and ritonavir among patients with MERS infection was initiated in Saudi Arabia . As Remdesivir may have potent efficacy to treat MERS-CoV and SARS-CoV infections [22, 23], clinical trials of Remdesivir in COVID-19 were initiated in China. It is recommended to use intravenous immunoglobulin to enhance the ability of anti-infection for severe patients. Corticosteroids (methylprednisolone 1–2 mg/kg per day) are recommended to control inflammatory-induced lung injury for patients with acute respiratory deficiency syndrome for a short duration. Corticosteroids may be a double-edged sword as it did not have an effect on mortality, but rather delayed viral clearance [24–26]. Otherwise, antibiotics therapy, oxygen support therapy and symptomatic therapy are all needed in management of COVID-19. ICU care and vital support are urgent if vital signs are unstable. In our study, days from symptom onset to undetectable SARS-CoV-2 RNA were 20.5 ± 12.1, days from admission to undetectable SARS-CoV-2 RNA were 16.7 ± 11.6. A retrospective cohort study shown median duration of viral shedding was 20.0 days in survivors . It indicated that SARS-CoV-2 invaded into human body and sustained for a long time, although antiviral therapy what we thought to be effective for SARS-CoV-2 was given to the patients. No statistical differences were found between mild and severe type patients in days from symptom onset to undetectable SARS-CoV-2 RNA or days from admission to undetectable SARS-CoV-2 RNA. The duration for positive SARS-CoV-2 RNA in the two types of patients was similar.
This study has several limitations. First, only fifteen COVID-19 patients were included without pediatrics or adolescent patients; suspected but exclusive diagnosed cases were ruled out in the analyses. Second, final clinical outcome of all patients was unavailable at the time of analysis. Third, changes of viral load and antibody titers were not available since the patients were confirmed diagnosed.
However, the patients enrolled in this study are treated in Guangzhou, giving new perspectives out of the origin city Wuhan in China. The data in this study permit an early assessment of clinical features of mild type and severe type patients with COVID-19.